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Access to Care in a Medicaid Managed Care World
Each state might look a little different, but Medicaid in all states is moving toward some kind of managed care, stated Matt Salo. And a newly proposed rule from CMS regulating access, enrollment, financing and more is an attempt to get everyone on the same page. But some people are concerned that this rule will stifle innovation in the states, Salo said.
People are appropriately distrustful, though, according to Margaret E. O’Kane, MHA, because it’s a new way of doing things and the success of managed care depends on a “vigorous accountability agenda.”
“There’s going to be a lot of pushback from people that are used to working only in fee-for-service and in a different situation,” she said.
Access to care for Medicaid has been a longstanding issue, Austin Frakt, PhD, said, and it remains a complex one because there are a variety of ways to measure access. The new regulations were concerning, in a way, because he found them vague, and that they put a lot of the burden back on states to put a plan in place for standards to measure access to care without specifying what it should look like.
The National Committee for Quality Assurance will be monitoring the situation, O’Kane said, especially since the industry has been in a period of very broad networks, and now the discussion is about narrow networks.
“It’s kind of a new day for us,” she said.
ACOs’ Focus on Rooting Out Fraud Aligns With CMS Vision Under Oz
April 23rd 2025Accountable care organizations (ACOs) are increasingly playing the role of data sleuths as they identify and report trends of anomalous billing in hopes of salvaging their shared savings. This mission dovetails with that of CMS, which under the new administration plans to prioritize rooting out fraud, waste, and abuse.
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New Research Challenges Assumptions About Hospital-Physician Integration, Medicare Patient Mix
April 22nd 2025On this episode of Managed Care Cast, Brady Post, PhD, lead author of a study published in the April 2025 issue of The American Journal of Managed Care®, challenges the claim that hospital-employed physicians serve a more complex patient mix.
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Contributor: For Complex Cases, Continuity in Acute Care Is Necessary
April 23rd 2025For patients with complex needs and social challenges like unstable housing, the hospital has become their de facto medical home—yet each visit is a fragmented restart, without continuity, context, or a clear path forward.
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Personalized Care Key as Tirzepatide Use Expands Rapidly
April 15th 2025Using commercial insurance claims data and the US launch of tirzepatide as their dividing point, John Ostrominski, MD, Harvard Medical School, and his team studied trends in the use of both glucose-lowering and weight-lowering medications, comparing outcomes between adults with and without type 2 diabetes.
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